UMR Possible Third Party Liability

Member Third Party Liability Information:

If you received a request from either CNIC or UMR for Third Party Liability Information please complete the form below. By completing this form a determination can be made as to whether CEBT or some other entity is the primary payor responsible for claims that have been submitted.

Member Name: First, Last:

Email:

Member ID:

Patient Name:

Services Provided By:

Date of Service:

Total Charge Amount:

Was Claim Due to Injury?

Yes

No

If no, then complete the certification at the bottom of this page and submit.